The capacity challenge: workforce, funding and beds

Leaders and managers across the health service gathered in Liverpool in mid-June for the annual NHS ConfedExpo conference, with much focus, understandably, on the huge pressure facing all services across the NHS. At the REAL Centre we have been working to understand what’s going on: how far are these service pressures a temporary COVID-19 recovery issue, or do they reflect more fundamental, underlying challenges?

Although the health service is under intense pressure and performance standards across the board are being missed – ambulance response times, A&E waiting, cancer referrals and waiting times for surgery are all way below performance targets – this is not simply the result of unprecedented demand. In fact, activity for many services remains below 2019 levels. The very real challenges the service is facing seem to stem more from pressures on capacity rather than a surge in demand.

At NHS ConfedExpo we led a session on the funding outlook and overall pressures for the next decade. The slides give an overview of the funding position for this. The government is increasing funding by just over 3% a year in real terms; more than double the rate of funding growth of the last decade, but well below the long-run average (3.6% a year). This decade will see significant demand pressures as the UK population ages – the ONS project there will be a third more people older than 85 in 2030 compared with 2018, and the number of people in their last year of life is expected to be a fifth higher. The very elderly and those at the end of life tend to need a lot of emergency care and to stay in hospital for longer. As a result, our modelling suggests that without significant changes to the way we provide care, emergency admissions in this decade will rise by more than elective care.

At the end of May we published a paper on what such a rise in demand might mean for the number of staff the NHS needs. Our central projection, taking into account further, albeit relatively slow, reductions in the time spent in hospital, is that around 314,000 more full-time equivalent NHS staff would be needed over and above existing vacancies in England in 2030/31 (relative to 2021/22). This would allow the NHS to return to the standards of care pre-pandemic. The analysis shows that reductions in length of stay and increases in day case rates are important. Without further progress on these two important sources of productivity growth, the additional demand for staff would be much higher (488,000 FTE staff by 2030/31).

Following the analysis of demand, we have been looking at how far workforce supply is on track to keep up – and therefore whether the NHS will face a shortfall of staff in the years to come. At the end of June we presented our findings for general practice at the RCGP annual conference. The results are stark: based on current trends and without a change in policy, by 2030/31 the NHS is likely to have a shortfall of one in four GPs and practice nurses. This poses a significant risk to access and quality of care. The reason is that demand for general practice services is projected to increase by a fifth over this decade but supply of GPs and practice nurses is not keeping up. Retention rates are critical. If retention worsens, the shortfall of GPs could be as much as one in two posts.

Of course, the challenges facing the NHS are happening against the backdrop of the cost-of-living crisis. The NHS Pay Review Body and the Review Body on Doctors' and Dentists' Remuneration are due to report any time, making recommendations for the pay award for NHS staff for 2022/23. The government has proposed a 3% uplift – well below inflation, which is now expected to reach over 10%. We published our analysis of the pay context for nurses and approach to pay setting in mid-June. This is a real case of being caught between a rock and a hard place – the NHS can’t afford to lose staff, as our forthcoming publication on the overall workforce gap will show. But, every additional 1% on NHS pay adds £900m to NHS costs, money that the health service simply doesn’t have.

As well as staff the NHS also needs to invest in its infrastructure, in particular bed supply, to meet rising demand. Our recent analysis on bed capacity found that to deliver pre-pandemic rates of care for patients the NHS would require a far larger increase in bed supply than we would expect under the government’s current hospital plan. Even if the NHS makes progress on reducing the time patients spend in hospital, the NHS would still need an additional 23,000 to 39,000 general and acute hospital beds. But even at this rate the NHS in England would still be at or below the average number of hospital beds per person relative to current levels in other OECD countries.

At the NHS ConfedExpo conference the (now former) Secretary of State reiterated his promise of a 15-year workforce strategy by the end of the year. With all the political turmoil it’s still imperative that the government doesn’t lose sight of the critical importance of setting out a long-term plan for the workforce. As our report on pay shows, the piecemeal, ‘muddling through’ approach to workforce is part of the problem. Next week we will publish our full workforce projections to shine a light on the scale of the challenge that the strategy needs to address and some of the priority areas for action. Look out for a webinar on the general practice workforce issues on 20 July.

Anita Charlesworth (@AnitaCTHF) is the Director of Research and the REAL Centre at the Health Foundation.